Association of radial versus femoral access with contrast-induced acute kidney injury in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

Acute Kidney Injury in Patients with Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention: The Role of Vascular Access Site

Background: in patients undergoing percutaneous coronary interventions (PCI), radial access should be favoured over femoral access as it reduces the risk of vascular complications and bleeding. Furthermore, a preventive role of radial access in the occurrence of acute kidney injury (AKI), mainly mediated by the reduction of bleeding and cholesterol crystal embolization into renal circulation, has been investigated in several studies, yielding conflicting results. Methods: we designed a retrospective study to appraise the effect of the use of a vascular access site on the occurrence of AKI in a cohort of 633 patients with acute myocardial infarction treated by PCI at our centre from 2018 to 2020. Results: after propensity score adjustment, radial access was associated with a reduced, albeit statistically not significant, incidence of AKI (14.7% vs. 21.0%; p = 0.06) and major bleeding (12.5% vs. 18.7%; p = 0.04) as compared to femoral access. At multivariate analysis, femoral access was an independent predictor of AKI, together with in-hospital occurrence of BARC 3-5 bleeding, Killip class >1 at presentation, female gender, baseline eGFR <60 mL/min, and baseline haemoglobin <12 g/dL. Conclusions: although limited by the observational design, our study supports the hypothesis that radial access may exert a protective role on the occurrence of AKI in patients with acute myocardial infarction undergoing PCI.

Association of Radial Artery Access with Reduced Incidence of Acute Kidney Injury

Objectives

To determine if radial artery (RA) access compared with femoral artery (FA) access for percutaneous coronary intervention (PCI) is associated with a lower incidence of acute kidney injury (AKI).

Background

AKI results in substantial morbidity and cost following PCI. Prior studies comparing the occurrence of AKI associated with radial artery (RA) versus femoral artery (FA) access have mixed results.

Methods

Using a large state-wide database, 14,077 patients (8,539 with RA and 5,538 patents with FA access) were retrospectively compared to assess the occurrence of AKI following PCI. To reduce selection bias and balance clinical data across the two groups, a novel machine learning method called a Generalized Boosted Model was conducted on the arterial access site generating a weighted propensity score for each variable. A logistic regression analysis was then performed on the occurrence of AKI following PCI using the weighted propensity scores from the Generalized Boosted Model.

Results

As shown in other studies, multiple variables were associated with an increase in AKI after PCI. Only RA access (OR 0.82; 95% CI 0.74-0.91) and male gender (OR 0.80; 95% CI 0.72-0.89) were associated with a lower occurrence of AKI. Based on the calculated Mehran scores, patients were stratified into groups with an increasing risk of AKI. RA access was consistently found to have a lower risk of AKI compared with FA access across these groups of increasing risk.

Conclusions

Compared with FA access, RA access is associated with an 18% lower rate of AKI following PCI. This effect was observed among different levels of risk for developing AKI. Although developed from a retrospective analysis, this study supports the use of RA access when technically possible in a diverse group of patients.

Radial Artery Access for Acute Coronary Syndromes: a Review of Current Evidence

PURPOSE OF REVIEW

To review the evidence supporting the use of transradial access (TRA) for percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS).

RECENT FINDINGS

There have been five major randomized controlled trials (RCTs) and two recent meta-analyses comparing outcomes of TRA and femoral access (FA) in ACS. Additional studies have explored the impact of TRA on STEMI door-to-balloon (D2B) times, TRA in high-risk ACS patients, the potential conflict between TRA and coronary artery bypass graft (CABG) surgery employing the radial artery, and distal radial artery (DRA) access. TRA is associated with a reduction in net adverse clinical events, major bleeding, acute renal injury, and access site complications compared to FA in ACS patients undergoing PCI. TRA is not associated with significant delays in STEMI D2B times that impact patient outcomes. Further studies are needed to evaluate the role of TRA in high-risk ACS patients, the interplay between TRA and radial artery CABG, and use of DRA in ACS.

Transradial versus Transfemoral Access and the Risk of Acute Kidney Injury following Primary Percutaneous Coronary Intervention in Patients with ST-Elevation Myocardial Infarction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Propensity-Score-Matched Studies

Objectives

The aim of this study is to examine the association between vascular access sites and the incidence of AKI in patients with STEMI undergoing primary PCI.

Background

Emerging evidence has suggested that transradial access (TRA) may be associated with lower rates of acute kidney injury (AKI) as compared with transfemoral access (TFA). However, most of these studies have included a nonselected study population undergoing diagnostic cardiac catheterization or percutaneous coronary intervention (PCI). Data on the association between TRA and AKI in this setting of STEMI are limited and with conflicting results.

Methods

We systematically searched PubMed, Embase, and Scopus for abstracts and full-text articles from inception to July 13^th of 2021. Studies included were randomized controlled trials (RCTs) and propensity-score-matched (PSM) studies evaluating the association of TRA versus TFA access with AKI in patients undergoing primary PCI for STEMI. Data were integrated using the random effects model and generic inverse‐variance method of DerSimonian and Laird.

Results

A total of 10,093 studies were found. After applying our inclusion criteria, 5 studies from 2014 to 2021 with a total of 8,536 STEMI patients were included. TRA was not significantly associated with a reduced risk for AKI compared with TFA (odds ratio 0.85, 95% CI 0.71–1.01, p 0.07, I² = 40%).

Conclusions

Transradial access was not significantly associated with lower risk of AKI in patients undergoing primary PCI for STEMI compared with TFA. Larger studies are needed to clarify this outcome.

Impact of radial access on contrast-induced acute kidney injury in patients with coronary artery bypass grafts

PURPOSE

We investigated the impact of radial access on contrast-induced acute kidney injury (CI-AKI) in patients with coronary artery bypass graft (CABG) undergoing cardiac catheterization.

METHODS

This retrospective monocenter study included 527 CABG patients undergoing cardiac catheterization via radial (58.1%, N = 306) or femoral access (41.9%, N = 221). Primary outcome measure was CI-AKI defined in accordance with the KDIGO criteria. Independent predictors for CI-AKI were assessed. 1-year mortality was assessed depending on the occurrence of CI-AKI.

RESULTS

In total, 99 CABG patients (18.8%) developed CI-AKI within 48 h after cardiac catheterization. Compared to patients without CI-AKI, amount of contrast media used (203.1 ± 102.6 ml vs. 204.2 ± 98.2 ml; P = 0.892) as well as procedural times (87.9 ± 44.8 vs. 79.8 ± 37.0; P = 0.190) were similarly. Regarding vascular access, there was no significant difference in the incidence of CI-AKI between radial and femoral approach (19.0% vs. 18.6%; p = 0.907). However, poor left ventricular ejection fraction (odds ratio [OR] = 1.72, P = 0.026), chronic kidney disease (OR = 2.30, P = 0.001) and acute coronary syndrome (OR = 1.64, P = 0.043) were independent predictors for CI-AKI. The occurrence of CI-AKI was significantly associated with an increased 1-year mortality (hazard ratio [HR] = 2.52, P = 0.003).

CONCLUSIONS

With 18.8%, CI-AKI is a frequent complication in CABG patients undergoing cardiac catheterization. Radial access did not decrease the risk when compared to the femoral approach.

Acute kidney injury after radial or femoral artery access in ST-segment elevation myocardial infarction: AKI-SAFARI

BACKGROUND

Acute kidney injury (AKI) complicating primary percutaneous coronary intervention (PCI) is an independent predictor of short- and long-term outcomes in patients presenting with ST-elevation myocardial infarction (STEMI). Prior studies suggest a lower incidence of AKI in patients undergoing PCI through radial artery compared to femoral artery access; however, no randomized clinical trials have specifically investigated this question in patients presenting with STEMI.

METHODS

To determine whether radial access (RA) is associated with a reduced frequency of AKI following primary PCI, we performed a substudy of the SAFARI-STEMI trial. The SAFARI-STEMI trial was an open-label, multicenter trial, which randomized patients presenting with STEMI to RA or femoral access (FA), between July 2011 and December 2018. The primary outcome of this post hoc analysis was the incidence of AKI, defined as an absolute (>0.5 mg/dL) or relative (>25%) increase in serum creatinine from baseline.

RESULTS

In total 2,285 (99.3%) of the patients enrolled in SAFARI-STEMI were included in the analysis-1,132 RA and 1,153 FA. AKI occurred in 243 (21.5%) RA patients and 226 (19.6%) FA patients (RR: 0.91, 95% CI: 0.78-1.07, P = .27). An absolute increase in serum creatinine >0.5 mg/dL was seen in 49 (4.3%) radial and 52 (4.5%) femoral patients (RR: 1.04, 95% CI: 0.71-1.53, P = .83). AKI was lower in both groups when the KDIGO definition was applied (RA 11.9% vs FA 10.8%; RR: 0.90, 95% CI: 0.72-1.13, P = .38).

CONCLUSIONS

Among STEMI patients enrolled in the SAFARI-STEMI trial, there was no association between catheterization access site and AKI, irrespective of the definition applied. These results challenge the independent association between catheterization access site and AKI noted in prior investigations.

Comparison of acute kidney injury with radial vs. femoral access for patients undergoing coronary catheterization: An updated meta-analysis of 46,816 patients

Trans-radial access for percutaneous coronary intervention or angiography has gained popularity amongst interventional cardiologists. Radial access is also thought to reduce the incidence of acute kidney injury (AKI) in the immediate post-operative period. The purpose of the present study was to perform a comprehensive updated systematic review and meta-analysis comparing the incidence of AKI following the radial vs. femoral route of coronary catheterization. An electronic literature search of the PubMed, BioMed Central, Scopus, Cochrane Central Register of Controlled Trials and Google Scholar databases up to 1st January 2020 was performed. A total of 14 studies were included, 2 of which were randomized controlled trials (RCTs), and 6 studies utilized propensity score matching. Comparison of the data of 21,479 patients in the radial group and 25,337 patients in the femoral group indicated a reduced incidence of AKI with the radial route [odds ratio (OR):0.66, 95% CI: 0.54-0.81, P<0.0001, I²=74%]. Similar results were obtained with sub-group analyses for RCTs (OR: 0.87, 95% CI: 0.77-0.98, P=0.02, I²=0%), retrospective studies (OR: 0.57, 95% CI: 0.36-0.90, P=0.02, I²=86%) and propensity score-matched studies (OR: 0.63, 95% CI: 0.48-0.83, P=0.0009, I²=45%). Multivariable-adjusted ORs of AKI for the radial vs. femoral route were extracted from non-RCTs and pooled for a meta-analysis, which also demonstrated similar results (OR: 0.70, 95% CI: 0.57-0.88, P=0.002, I²=70%). Within the limitations of the study, the present results indicate that, as compared to femoral access, the use of trans-radial access for coronary catheterization is associated with a significantly reduced incidence of AKI. A reduction of AKI by ~34% may be expected with the use of radial access.

Association between the risks of contrast-induced nephropathy after diagnostic or interventional coronary management and the transradial and transfemoral access approaches

Introduction: The risk of contrast-induced nephropathy (CIN) as a common and important complication of coronary procedures may be influenced by the vascular access site. We compared the risks of CIN in diagnostic or interventional coronary management between patients treated via the transradial access (TRA) and those treated via the transfemoral access (TFA). Methods: Patients undergoing invasive coronary catheterization or percutaneous coronary intervention (PCI) were enrolled. We excluded patients with congenital or structural heart disease and those with end-stage renal disease on dialysis. Based on the vascular access site used for invasive coronary catheterization, the patients were divided into 2 study groups: the TFA and the TRA. CIN was defined as an absolute (≥0.5 mg/dL) or relative (>25%) increase in the baseline serum creatinine level within 48 hours following cardiac catheterization or PCI. Results: Overall, 410 patients (mean age = 61.3 ± 10.8 years) underwent diagnostic or interventional coronary management: 258 were treated via the TFA approach and 152 via the TRA approach. The patients treated via the TFA had a significantly higher incidence of postprocedural CIN (15.1% vs 6.6%; P= 0.01). The multivariate analysis showed that the TFA was the independent predictor of CIN (OR: 2.37, 95% CI: 1.11 to 5.10, and P= 0.027). Moreover, the BARC (Bleeding Academic Research Consortium) and Mehran scores were the other independent predictors of CIN in our study. Conclusion: The risk of CIN was lower with the TRA, and the TFA was the independent predictor of CIN after the diagnostic or interventional coronary management.

An Update on Radial Artery Access and Best Practices for Transradial Coronary Angiography and Intervention in Acute Coronary Syndrome: A Scientific Statement From the American Heart Association

Transradial artery access for percutaneous coronary intervention is associated with lower bleeding and vascular complications than transfemoral artery access, especially in patients with acute coronary syndromes. A growing body of evidence supports adoption of transradial artery access to improve acute coronary syndrome-related outcomes, to improve healthcare quality, and to reduce cost. The purpose of this scientific statement is to propose and support a "radial-first" strategy in the United States for patients with acute coronary syndromes. This document also provides an update to previously published statements on transradial artery access technique and best practices, particularly as they relate to the management of patients with acute coronary syndromes.

Acute kidney injury in patients with myocardial infarction undergoing percutaneous coronary intervention using radial versus femoral access

BACKGROUND

Data on radial access (RA) as an independent risk factor for acute kidney injury (AKI) in myocardial infarction (MI) patients are conflicting. Our aim was to assess how RA influences the incidence of AKI in MI patients undergoing percutaneous coronary intervention (PCI).

METHODS

Data from 3842 MI patients undergoing PCI at our institution from January 2011 to December 2016, of which 35.8% were performed radially, were retrospectively analyzed. A propensity-matched analysis was performed to adjust for differences in the baseline characteristics between the RA and femoral access (FA) groups. The effect of RA on the incidence of AKI was observed.

RESULTS

In the unmatched cohort, AKI occurred less often in the RA group [77 (5.6%) patients in the RA group compared to 250 (10.1%) patients in the FA group; p = 0.001]. After propensity-matched adjustment, the incidence of AKI was similar in the two groups. After adjustment for potential confounders, RA was not identified as an independent predictive factor for AKI in either the unmatched or the propensity-matched cohort. Bleeding, heart failure, age ≥ 70 years, renal dysfunction, and the contrast volume/GFR ratio predicted AKI in both cohorts. Additionally, diabetes, contrast volume, and hypertension were predictive of AKI in the unmatched cohort.

CONCLUSION

The access site was not independently associated with the incidence of AKI in patients with MI in both a non-matched and a propensity-matched cohort. Our study result suggests that the lower incidence of AKI in patients treated with RA in an unmatched cohort might be substantially influenced by confounding factors, especially bleeding.

Acute Kidney Injury Post Cardiac Catheterization: Does Vascular Access Route Matter?

BACKGROUND

Acute Kidney Injury as a complication of cardiac catheterization is associated with increased length of hospital stay and mortality. In recent years, the use of the radial artery for cardiac catheterization is increasing in frequency.

OBJECTIVE

The objective of this concise review was to evaluate the method of cardiac access site and its impact on Acute Kidney Injury following cardiac catheterization.

METHODS

After a thorough search on Medline, Google Scholar and PubMed, we included all the literature relevant to Acute kidney injury following transradial and transfemoral cardiac catheterization.

RESULTS

While acute kidney injury was caused due to a variety of reasons, it was important to consider each case on an individual basis. We found a trend towards increased use of transradial approach in patients at high risk of developing kidney injury. However, limitations such as operator experience, anatomical challenges and so on do exist with this approach.

CONCLUSION

Transradial access offers several advantages to a patient at high risk of acute kidney injury undergoing cardiac catheterization. Further large studies are needed to establish this trend in the years ahead.